Minor foot wounds such as blisters or cuts can cause serious complications if left unattended. This is even more true in people living with diabetes, because these patients often experience a loss of sensation in their lower extremities.
“As a side effect of poorly controlled blood sugar over time, these patients lose sensation in their feet and are unaware of the extent of the damage that’s occurring,” explains Dr. Michael Stempel, Chief in the Division of Podiatry and the Director of the Podiatry Center at The George Washington Medical Faculty Associates. “Even small issues, such as an ingrown nail, blister, or a cut can turn into a deep wound or infection that threatens their limb.”
Preventative Management
With any patient living with diabetes, the goal is always to control blood sugar for the best outcomes. However, in order to mitigate the specific potential for diabetic foot ulcers, Dr. Stempel advises a daily preventative routine.
“Daily practices such as checking your feet in good light, being careful about what shoes you wear, and avoiding walking barefoot, especially in the outdoors, is the general advice we give every diabetic patient—even when they're just newly diagnosed, without any particular risk or loss of sensation,” he notes.
Wearing shoes in the correct size and structure is a critical component. It’s common for a patient’s feet to grow one or two sizes, especially if there’s been accompanying weight gain or other foot deformities. Given the loss of sensation, patients may not even perceive their current footwear is simply too tight. Shoes that are worn out, lack support, or are too narrow in the toe box (e.g. high heels) are also causes for concern.
“Nobody wants to hear they shouldn’t wear their cute shoes anymore, but the reality is that shoes that are excessively narrow, pointy, and a heel height greater than an inch or so is going to put more and more pressure on the front part of the foot,” states Dr. Stempel. “That’s the area where patients with neuropathy are most likely to develop wounds.”
Red Flags
Unfortunately, even the “smallest” of injuries are often more significant than they appear. A blister, redness or discoloration, bruising, or swelling surrounding a callous or corn are all red-flag symptoms that should be looked at sooner than later.
“The best advice I can give somebody is that if they're not sure what they’re looking at, get it looked at,” advises Dr. Stempel. “They should see their primary care provider. They should see their podiatrist. They should call and say, ‘I am diabetic. I see something on my foot and I'm not sure what’s going on.’”
If an actual wound is present—an open area of skin—it should be professionally evaluated within days.
Preliminary Treatment
The first thing Dr. Stempel and his colleagues do when seeing a patient with a foot ulcer is to immediately evaluate it for the presence of infection. “We’ll often get an x-ray to see if there are any changes underneath the skin involving the bones or joints and check circulation and blood flow. If there isn’t adequate blood flow, the body will not be able to clear infection and won't be able to heal the wound,” he explains. “Once we've checked for these things—and assuming there isn’t something more serious going on that requires immediate hospitalization, such as if there was an abscess or a deeper infection—we’ll then focus on getting pressure and weight off of the wound.”
Per Dr. Stempel, much of the focus when treating patients in the wound center is choosing the appropriate therapy to keep the wound moist, clean, healthy, free of infection, and to limit weight and pressure.
Advanced Therapies
When wounds are deemed to be more complex, the podiatry center has other modalities to help facilitate the healing process. One such therapy is using negative pressure dressing, which is commonly called a “wound vac” and puts suction and deforming stress on the skin to help tissue grow faster. Another option is hyperbaric oxygen therapy (HBOT), which involves 60-90 minutes in a pressurized oxygen chamber. This increases the amount of oxygen available in the blood.
“We also have tissue grafts that are grown in the lab, as well as various types of collagen grafts and other high-tech dressings that wick moisture off of the wound and have antibiotic properties without being excessively harsh to fragile wound tissue,” shares Dr. Stempel.
Surgical Intervention
No one wants to think about “going under the knife,” but surgical intervention doesn’t necessarily equate to amputation.
“The sad thing is that I've had patients—way too often—who are afraid to come in because of advice they’ve heard in their community or from family. ‘Don’t let them start cutting on you because once they start cutting on you, then you're just going to lose your leg.’ They don’t understand that they're creating their own reality; one which is guaranteeing the worst case scenario,” warns Dr. Stempel. “If there is an infection, it needs to be drained. If there is advanced destruction of bone that’s threatening the rest of the foot or the leg, that’s a case where we need to do surgery.”
Separate from infection, at times wounds simply need to be debrided. This involves using surgical instruments to clean away tissue that’s unable to heal—tissue that has been damaged, is unhealthy, or doesn’t have adequate blood flow. By removing what’s unhealthy, the healthy tissue is allowed to recover.
“I liken it to fighting a forest fire. Sometimes, you have to sacrifice one part of the forest in order to save the rest of the forest. If the fire is burning out of control in one area, it’s only going to spread,” says Dr. Stempel. “I also try to break it down in terms of taking steps along a path… while the immediate step that we’re taking may seem scary, we’re trying to avoid the more dangerous and truly scary things that would be required from neglect of care such as amputation.”
Listen to the Podcast with Dr. Michael Stempel
